Inadequate supervision has been blamed for the death of a 17-year-old Canberra boy during a school activity on Mount Ainslie five years ago.
Adriaan Roodt suffered catastrophic head injuries when a large log fell on his head while he and several others were playing a game of Capture the Flag, in which players run into the territory of the other team to capture their flag without being tagged.
Those who are tagged are put in "jail" where they sit out the game or wait until they are rescued.
The court heard that during the game, Adriaan and a number of his friends had been tagged and were sitting in "jail" when one of them decided to try to lift a heavy log nearby.
After several efforts involving several other boys, including Adriaan, the branch was lifted up but then let go because of the weight.
The coronial inquest heard Adriaan did not manage to jump out of the way quickly enough and was struck, suffering traumatic head injuries.
No teacher saw the accident.
Police later measured the log at six metres long and weighing 185 kilograms.
Adriaan died later in hospital.
'With greater supervision, Adriaan's death was preventable'
On Friday, Coroner James Stewart detailed how the boys had been in a place out of sight of the teachers supervising the game when they began to try to lift the log.
"The schoolboys became mischievous and misbehaved," Coroner Stewart said.
"They made multiple attempts to lift the log. That whole log-lifting activity cannot have been only confined to mere seconds.
"Adequate supervision should have swiftly resolved this behaviour and ensured a very different outcome for Adriaan."
But Coroner Stewart stopped short of blaming the teachers, instead taking aim at the ACT's Education Directorate for not maintaining adequate policies, procedures and training for teachers in safety risk analysis.
"There was an almost impossible maze of policy for the teachers to navigate," Coroner Stewart said.
He also noted there were too few staff to supervise the game.
Witnesses gave varying accounts of the way risk assessments worked, with one noting the game had seemed safe.
"There had never been any significant injuries during the game until this day," the witness said.
The witness said the nearest safety risk had been a snake seen by one of the students.
"The Education Directorate failed to correctly administer their policies for excursions and activities at the time of Adriaan's death," Coroner Stewart said in his formal findings.
And he said there was insufficient access, training and compliance checking on the policies that were in place.
"The failure to have conducted an adequate risk assessment or management plan represents a lost opportunity to have conducted the Capture the Flag activity in a different way," he said.
"An adequately conducted risk assessment or management plan should have resulted in a different outcome for Adriaan and his family.
"I find that with greater supervision, Adriaan's death was preventable."
Coroner Stewart called for better training for teachers, an enhancement of risk-assessment capability within the ACT's Education Directorate, and for the attorney-general to review the application of Work Health and Safety Laws to the directorate to ensure children and staff were kept safe.
Adriaan's family released a statement after the findings were released, welcoming the report.
"Now we can only hope that these recommendations, when implemented, will prevent another child sustaining an injury during an outdoor education session and whilst in the care of a school," Adriaan's mother Sandra Roodt said.
